Continuing Care at Eagles Trace

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 2-Staff were observed without hair restrains. 1 small transparent square container was observed in the dry storage room which held multiple (unable to count)insects. 1 live insect was observed in the dry storage room. These failures could place residents at risk of foodborne illness and disease. Findings Included: On 9/17/25 at 11:51 AM a delivery driver was observed in the kitchen preparation area; there was no hair restraint donned (worn). Observation and interview on 9/17/25 at 11:54 AM of Chef A in the food preparation area, there was no hair restraints donned. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the residents' rights to privacy for 1 (Resident #17) of 7 residents reviewed for personal privacy. The facility failed to ensure that certified nursing assistant (C.N.A.) A and Program Assistant (PA) A maintained Resident #17's privacy while resident received a shower from private caregiver. This failure place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for one (Resident#3) out of 4 residents reviewed for ADLs. The facility failed to provide timely incontinent care for Resident #3 which resulted in the resident's brief, towel on top the drawsheet, draw sheets and bed linen to be soaked with urine. This deficient practice could place residents at risk of skin breakdown and reduced feelings of self-worth.

Inspectors wroteBased on interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #25) out of 7 residents reviewed for adequate supervision. The facility failed to ensure Resident #25 who required supervision and assistance while receiving a shower was left unattended. This deficiency exposed residents living in the facility to potential harm, injury or death due to not being adequately monitored. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 4 residents (Resident #3) reviewed for incontinent care. The facility failed to ensure CNA K properly cleaned Resident #3 during incontinent care. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain an effective pest control program so that the facility is free of for rooms in 1 of 1 kitchen reviewed for environment.1 small transparent square container was observed in the dry storage room which held multiple fruit flies. 1 live insect was observed in the dry storage room. These failures could place residents at risk of foodborne illness and disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/preparation discarded after 72 hours. 3. The facility failed to keep food off the floor. 4. The facility failed to keep scoops in a separate holder from bulk food bin. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility's kitchen on 08/13/24 at 8:15 AM revealed the following. 1. A plastic container of Blue Cheese had No Label and No use by Date. 2. A Plastic container of sliced Swiss Cheese in the walk-in cooler had a used by date of 8/10/24. 3. A cs of fresh sliced mushroom in the walk-in cooler had a use by date of 8/09/24 4. 2cs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters dumpster A and dumpster B reviewed for Food and nutrition services. -The facility failed to ensure all garbage was dispose properly in the dumpster and not left outside of dumpster. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensured that residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary trat infections and restore continence to the extent possible in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #13) residents reviewed for quality of care. The NF failed to secure Resident #13 suprapubic catheter tubing to prevent from dislodging. This failure could place residents at risk for injury, hospitalization, and decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for standards in 1 of 1 medication (Resident #83) rooms reviewed for medication storage. -The facility failed to discard Resident #83 medication IV antibiotic cefepime that expired on 08/14/2024. This failure could place residents at risk for not receiving adequate antibiotic therapy to treat infection.

Inspectors wroteBased observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 storage rooms (Room A and Room B) reviewed for infection control. -The facility failed to keep infection control gowns and pillows off the floor in the storage rooms. This failure could place residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on interview, and record review, the facility failed to immediately assess the resident, consult with the physician, and immediately transport the resident to the hospital when a change in condition occurred for 1 of 1 resident (CR #6) was reviewed for a change of condition: 1. The facility failed to assessed CR #6 for more than 3.5 hours after the CA identified a change in resident's condition to include slurred speech and elevated blood pressure. 2. The facility failed to notified CR #6's physician for more than 4 hours after CA identified a change in condition. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 08/06/2023 and ended on 08/06/2023. The facility corrected the noncompliance before the investigation began. These failures resulted in an IJ on 11/17/2023. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs to meet the needs for 5 of 5 Residents (#1, #2, #3, #4 and CR #5) reviewed for pharmacy services in that: Medication Aide (MA) failed to follow medication administration policies resulting in Resident #1, #2, #3, #4 and CR #5 receiving double doses of medication. MA failed to follow the posted medication administration schedule for Resident #1, #2, #3, #4 and CR #5. MA failed to document the start date for Resident #1, #2, #3, #4 and CR #5's medications. MA failed to monitor medication administration as CR#5 was discovered deceased with medications in his mouth. These failures could place all residents at risk of drug diversion, health decline, and/or death. The noncompliance was identified as PNC. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.